Table 3.
Results of multivariable analyses to identify factors associated with hospitalizations for P&I as the primary diagnosis among U.S. long-term care facility residents, 2013–2015
| Characteristics | Short-staya HR (99% CI)c |
Long-stayb HR (99% CI)c |
|---|---|---|
| Age group (ref = 65–74) | ||
| 75–84 | 1.08 (1.00, 1.17) | 1.11 (1.06, 1.15) |
| 85+ | 1.16 (1.06, 1.27) | 1.23 (1.18, 1.28) |
| Sex (ref = male) | 0.84 (0.79, 0.89) | 0.83 (0.80, 0.85) |
| Race and ethnicity | ||
| Non-Hispanic White (ref = non-White) | 1.00 (0.87, 1.15) | 1.03 (0.97, 1.11) |
| Non-Hispanic Black (ref = non-Black) | 0.86 (0.72, 1.03) | 0.89 (0.82, 0.97) |
| Hispanic (ref = non-Hispanic) | 1.02 (0.82, 1.27) | 1.05 (0.95, 1.15) |
| Location resident is admitted from (ref = hospital) | ||
| Community or home | 0.81 (0.67, 0.98) | 0.79 (0.76, 0.83) |
| Another LTCF or swing bedd | 0.99 (0.77, 1.26) | 0.92 (0.87, 0.97) |
| Other location | 0.78 (0.60, 1.02) | 0.86 (0.81, 0.93) |
| Type of admission is reentry (ref = new) | 6.50 (6.09, 6.95) | 1.43 (1.39, 1.47) |
| Body mass index, kg/m2 (ref = 18.5–24.9, normal) | ||
| < 18.5, underweight | 1.14 (1.03, 1.25) | 1.05 (0.99, 1.11) |
| 25–29.9, overweight | 0.88 (0.82, 0.95) | 0.98 (0.95, 1.01) |
| ≥ 30, obese | 0.74 (0.68, 0.81) | 0.98 (0.95, 1.02) |
| Current tobacco use (ref = no tobacco use) | 0.87 (0.72, 1.06) | 1.01 (0.95, 1.07) |
| Clinical Characteristics from MDS | ||
| Cancer | 1.20 (1.10, 1.32) | 1.00 (0.94, 1.07) |
| Atrial fibrillation or other dysrhythmias | 1.13 (1.06, 1.21) | 1.05 (1.01, 1.08) |
| Coronary artery disease | 1.00 (0.94, 1.07) | 1.01 (0.98, 1.04) |
| Heart failure | 1.00 (0.92, 1.08) | 1.13 (1.08, 1.18) |
| Hypertension | 1.02 (0.95, 1.10) | 0.99 (0.96, 1.02) |
| History of pneumonia | 3.60 (3.36, 3.85) | 1.38 (1.29, 1.46) |
| Diabetes mellitus | 0.98 (0.91, 1.05) | 1.02 (0.99, 1.06) |
| Arthritis | 0.92 (0.85, 0.98) | 0.95 (0.92, 0.98) |
| Alzheimer’s disease | 0.79 (0.67, 0.94) | 0.89 (0.86, 0.93) |
| Cerebrovascular accident, transient ischemic attack, or stroke | 0.80 (0.72, 0.89) | 0.89 (0.86, 0.93) |
| Non-Alzheimer’s dementia | 0.91 (0.84, 0.99) | 0.87 (0.84, 0.89) |
| Depression | 0.98 (0.92, 1.05) | 1.07 (1.05, 1.10) |
| Asthma, chronic obstructive pulmonary disease, chronic lung disease | 1.48 (1.38, 1.58) | 1.56 (1.51, 1.61) |
| Respiratory failure | 1.11 (0.99, 1.24) | 1.13 (1.03, 1.24) |
| Parkinson’s disease | 0.82 (0.69, 0.97) | 0.95 (0.90, 1.00) |
| Geriatric Syndromes | ||
| Cognitive Function Scale score (ref = no/mild impairment) | ||
| Moderate cognitive impairment (2, 3) | 0.95 (0.89, 1.02) | 0.90 (0.87, 0.92) |
| Severe cognitive impairment (4–6) | 1.21 (1.01, 1.45) | 0.92 (0.84, 1.01) |
| Activities of Daily Living 28-point Scale score (ref = None to limited assistance required) | ||
| Extensive assistance required (15–19) | 1.56 (1.45, 1.68) | 1.08 (1.05, 1.11) |
| Extensive dependency (≥20) | 1.91 (1.74, 2.08) | 1.08 (1.04, 1.12) |
| CHESS Scale score, overall health stability (ref = stable) | ||
| Minimal instability (1, 2) | 1.21 (1.12, 1.33) | 1.09 (1.04, 1.14) |
| Moderate to very high instability (3+) | 1.04 (0.84, 1.28) | 1.17 (1.04, 1.32) |
| Charlson comorbidity score (MDS) (ref = 0) | ||
| 1–2 | 1.10 (0.96, 1.26) | 1.04 (0.98, 1.10) |
| ≥ 3 | 1.15 (0.99, 1.34) | 1.12 (1.04, 1.19) |
| Urinary or bowel incontinence (ref = none) | 1.11 (1.04, 1.18) | 0.99 (0.96, 1.02) |
| Shortness of breath | 2.26 (2.09, 2.43) | 1.34 (1.28, 1.39) |
| Swallowing disorder | 0.91 (0.80, 1.03) | 0.96 (0.89, 1.04) |
| Tube feeding | 0.90 (0.76, 1.07) | 1.30 (1.20, 1.41) |
| Ventilator or respirator use while in facility | 1.48 (0.82, 2.67) | 1.34 (1.03, 1.75) |
| Prognosis: less than 6 months to live | 0.88 (0.61, 1.25) | 0.80 (0.62, 1.04) |
| Medication Use 6 months before index | ||
| Beers Criteria medication,e any use | 1.09 (1.03, 1.16) | 1.09 (1.06, 1.13) |
| Antipsychotics, any use | 0.86 (0.74, 1.01) | 0.81 (0.77, 0.86) |
| Opioid analgesics, any use | 1.11 (1.01, 1.23) | 0.97 (0.91, 1.03) |
| Antibiotics,f any use | 1.15 (1.08, 1.22) | 1.30 (1.27, 1.34) |
| Corticosteroids, any use | 1.10 (1.00, 1.22) | 1.10 (1.04, 1.17) |
| Proton pump inhibitors, any use | 1.04 (0.97, 1.12) | 0.87 (0.84, 0.91) |
| Influenza vaccine received for season of cohort entry | 0.99 (0.92, 1.05) | 1.09 (1.06, 1.13) |
| Pneumococcal vaccination up to date | 0.99 (0.92, 1.06) | 1.06 (1.03, 1.10) |
| Health Service Use 6 months before index | ||
| Any Hospitalizations | 1.04 (0.92, 1.18) | 0.91 (0.88, 0.94) |
| Any ICU use | 1.06 (0.99, 1.13) | 1.06 (1.02, 1.11) |
| Facility Structural Characteristics | ||
| Urban location (ref = non-urban) | 0.87 (0.80, 0.93) | 0.77 (0.74, 0.79) |
| Total bed size (ref = < 100) | ||
| 100–200 | 0.94 (0.88, 1.01) | 0.91 (0.88, 0.94) |
| > 200 | 0.93 (0.82, 1.06) | 0.89 (0.84, 0.94) |
| For profit facility (ref = not for profit) | 1.01 (0.90, 1.08) | 1.05 (1.02, 1.08) |
| Facility Staffing Type and Hours | ||
| Ratio of RN to RN + LPN (fifth vs. first quintile) | 0.91 (0.81, 1.02) | 0.90 (0.85, 0.95) |
| SLP on-staff hours / 100 Beds (fifth vs. first quintile) | 1.02 (0.94, 1.11) | 0.99 (0.98, 1.00) |
| LIP on-site (ref = none) | 1.02 (0.96, 1.08) | 0.93 (0.90, 0.95) |
| Total nursing hours/resident/day (fifth vs. first quintile) | 0.87 (0.78, 0.97) | 0.99 (0.95, 1.04) |
| Facility Care Quality | ||
| Antipsychotic use, % of residents (fifth vs. first quintile) | 1.00 (0.90, 1.10) | 1.07 (1.02, 1.11) |
| Restraint use, % of residents (fifth vs. first quintile) | 1.02 (0.94, 1.10) | 1.07 (1.04, 1.11) |
| Pressure ulcers, % of residents (fifth vs. first quintile) | 0.96 (0.87, 1.05) | 1.01 (0.96, 1.05) |
Values in boldface indicate statistically significant associations at the 0.01 level
Abbreviations: LTCF long-term care facility, MDS Minimum Data Set, CHESS Changes in Health, End-stage disease and Symptoms and Signs, RN Registered Nurse, LPN Licensed Practical Nurse, SLP Speech Language Pathologist, LIP Licensed Independent Practitioner
a N = 1,080,816 after 37,238 (3.3%) were excluded from regression due to missing data on facility-level variables
b N = 571,694 after 21,749 (3.7%) were excluded from regression due to missing data on facility-level variables
c We used robust Huber-White standard errors to account for clustering of residents within LTCFs
d Swing beds are LTCF beds that can serve both short-stay and long-stay residents depending on need
e The Beers criteria is a specific list of potentially inappropriate medications that are not recommended for use among older adults in most circumstances or under specific situations
f Antibiotics recommended in the Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults